38. Preschool Behavior: When is it a problem?

Around one and 10 preschool age, children, struggle with significant emotional and behavior problems, but it can be incredibly difficult to tell. How can you tell When a preschool age child might need further evaluation?
In this episode, we talk about how to use a brief tool to determine whether a preschools behavior is normal, or may benefit from further evaluation. This tool is called the brief early childhood screening assessment, or the brief ECSA  for short.

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Transcript

Dr. Elise Fallucco: 0:21

Welcome back to psyched for paeds, the child mental health podcasts for pediatric clinicians. And for all of us who take care of kids, we're helping you help kids. I'm your host, Dr. Elise Fallucco child psychiatrist and mom. We're going to be talking about emotional and behavioral problems in preschool aged kids. And how common they are. How easy it is. To not recognize what's going on. And how it can be incredibly helpful to identify these kids early, before these problems grow and get them intervention so that they don't grow up into children and adolescents with more serious psychiatric problems. And I'm most excited that I'm going to be sharing with you, how you can use a standardized tool to help distinguish between normal developmentally typical childhood behavior and red flags, concerning behavior that requires further evaluation and assessment. And of course, we're going to be sharing with you this free tool that you can use in your practice. So let's start from the very beginning. What we know is that about 10% of preschool aged kids experienced significant behavioral and emotional problems that interfere with their lives in childcare settings at home with their siblings, with friends. I just want to go and restate that fact. One out of 10 preschool aged kids have significant behavioral and emotional problems that could benefit from intervention and treatment. And yet I think the common wisdom is we'd like to think that a lot of these kids will grow out of these things that they'll develop and that they'll mature. And that these problems will go away. But the reality is. That the majority of these kids have problems that persist into early childhood. And into elementary, middle, and high school and beyond. And yet. It is so easy to miss these problems. It's so easy to push them under the rug to not realize that there is something going on. And in doing so we miss the opportunity for early intervention and to offer support to these kids and to their parents. To help them feel better and help support the parents and families. So before I tell you about this amazing standardized tool that can help you distinguish between normal behavior and something that requires further evaluation and assessment. I know what you're thinking. Another tool, another standardized screening tool. We are so busy and we have a lot of things that we need to do. And I just want to remind everybody that the purpose of these tools is not only to help us identify kids at risk that we might miss. Also, it's a way to streamline the visit and to help us potentially save time. And from all of our studies, what we know is that. By just relying on our clinical intuition, by just relying on the exam of the child in the room for that brief well visit, we're going to miss a lot of cases. And in addition, we know that very few parents spontaneously bring up their own concerns with their child's behavior, to their pediatrician. And so if we're not using a well validated standardized tool to help assess things, We're going to be under identifying these kids and missing opportunities for early intervention. One of the most difficult things to disentangle when you're dealing with a preschool aged child is to figure out what is normal. We know that temper tantrums are normal, but when does it become something that's more than just normal? And if this is a clinical question that we as child psychiatrists even struggle at times to parse out. Can you imagine how difficult it is for parents, particularly new parents to be able to figure out if what their child is doing is typical. Or if this could be a sign that they may need further evaluation. In order to help clinicians figure out if a child is struggling with significant behavioral and emotional problems that could benefit from further evaluation and potentially treatment. Our colleagues developed the early childhood screening assessment. Or the exa E C S a for short. So this screening tool was specifically designed to be used in a primary care setting. And the exit consists of 36 items that caregivers are asked to complete about their child's behavior. So parents are asked compared to other children this age, how often does your child exhibit the following things seems nervous or worries? A lot loses their temper too much. Argues with adults is very disobedient. And so the parents are asked to rate some of these items on a scale of zero, which is never. To two, which is always, or almost always. And then the really amazing and fantastic part about the ECSA is that it also contains information about the caregiver themselves. And so the caregivers are asked to self-report. Symptoms of depression based on the patient health questionnaire, two item as well as symptoms of caregivers, stress. And I want to tell you about these two items that assess caregiver stress, because I think that they're relevant for the preschool age group, but also potentially for the rest of our child's lives. So these items are one, I feel too stressed to enjoy my child. And two, I get more frustrated than I want to with my child's behavior. So these two stress items are really picking up on the dynamics of the caregiver, child relationship. And most importantly, they're zooming in on how the caregivers emotional wellbeing is affecting their ability to take care of and relate to this child. And this is such a critically important issue, especially during early childhood. So the relationship between the caregiver and the child. Is critical for children helping to develop their own self-regulation and their own emotional and behavioral health. So it's so important that this particular scale is not just looking at child behavior problems in a vacuum, but also looking at the caregiver's wellbeing because the two things. Are so interrelated. And so when you heard that the exa contained 36 child items, you might've been thinking that's very long. So, this is the fun part where I get to tell you a little bit of a backstory so what I'm going to tell you about is a journey that we went on here locally to develop and validate a briefer version of the exa for use in pediatric primary care. I had the pleasure and opportunity to work with a bunch of pediatric practices here in Jacksonville, Florida. And we asked them to do a pilot period of administering the ECSA. Routinely at well visits for kids in the preschool age group. Well, the ECSA is validated for use in kids as young as 18 months old. And then as old as 60 months old. The practices we work with chose to administer it at the 48 month well visit or the four year well visit. It did not make sense for them to administer it at the 24 month, 36 month, 48 month and 60 month visits because there's so many other competing priorities at those other visits, not the least of which are vaccinations and autism screening and other developmental screening. And the feedback we got from them is that the screening tool help them detect money, more cases than routine history alone. Cases, both have children with behavioral and emotional problems as well as caregivers with significant stress or depression. They said it was feasible and practical for use, but perhaps unsurprisingly, they were concerned about the length of the instrument. it takes families about five to 10 minutes to complete. But the reality is, is if you're a parent in a pediatrician office with a preschooler crawling around your lap and running around the room. Completing 40 items feels like it takes a lot longer than five to 10 minutes. The reason why I tell you all of that is that based on their feedback, I had the pleasure to work with one of the developers of the original ECSA Dr. Mary Margaret Gleason, who is an child and adolescent psychiatrist who specializes in early childhood, emotional and behavioral problems. And Dr. Gleason and I use their feedback to develop and validate a much shorter version of the ECSA. Called the brief ECSA. Instead of having 36 items of child symptoms. We developed a version and validated a version that only includes 22 items. And this briefer version of the ECSA It has a cutoff score of nine or higher. And has 89% sensitivity and 85% specificity for identifying children with significant behavioral and emotional problems who could benefit from further assessment. We also validated it against very well-known screening tools and instruments such as the child behavior checklist, the pediatric symptom checklist, which I know all of our friends in pediatric primary care know and love, the brief infant toddler, social emotional assessment to name a few. So, what I would suggest for you to consider is to take a look at the brief ECSA, this tool with 22 child items. And then of course, the two caregivers stress and two caregiver, depression items. It's very simple to administer and score. You just add up all of the items that are endorsed as positive in column one and column two, to get a total score and scores of nine or higher are concerning. And as usual, the higher the score, the more concerned you would be. And for those who score positive. We'd recommend following up, talking with the family. Not only about their child's behavioral and emotional problems, but checking in. With the parents about their own level of stress and depression. And this is an important opportunity to just open the door and do what so many primary care pediatric clinicians are fantastic at and just validate the family experience, validate that it's really hard to be taking care of kids. In this age group. Really kids in any age group and especially for first time parents, and particularly for parents without a large system of social support. So my hope is that you'll try using this. You'll be able to identify kids who need help and that. You will then become another source of support for these families. And if needed may be able to point some of these families in the direction of further evaluation, additional support I know you have so many screening tools that you already use and have to do, but I hope you know and trust that when we talk about a screening tool on the site for paeds podcast, More often than not, we're recommending it because we feel that it not only offers you. Highly valuable clinical information. But that it ultimately helps save you time in making your own clinical assessment and determining the priority of the visit. So I would suggest that you consider using this at four year old well visits. As usual, you can access free copies of the brief ECSA on our website, psyched the number four paeds.com. We're going to continue the conversation about emotional and behavioral problems. In our little kids. Next week and we hope you'll join us. Thanks for listening. See you next time.